Interventional Pain Center

PAIN RELIEF TREATMENTS & PROCEDURES

Comprehensive Evaluation and Management Services

Patients are evaluated by a physician with board certification in anesthesiology and pain management. Our staff is complemented by a psychologist, physical and occupational therapists, and full-time nursing personnel.

Interventional Pain Specialist

Frank J. Adipietro, MD,
DABA, DAAPM, FIPP, DABIPP

CREDENTIALS

Professional Licenses:
National Board of Medical Examiners (NBME)
Diplomate of American Board of Anesthesiologists (DABA)
Diplomate of The American Academy of Pain Management (DAAPM)
Fellow of Interventional Pain Practice (FIPP)
Diplomate of American Board of Interventional Pain Physicians (DABIPP)

Professional Societies and Awards:
America's Top Anesthesiologists 2006-2008American Medical Student Association 1979-83
American College of Physicians 1983-Present
American Medical Association 1983-Present
American Society of Anesthesiologists 1984-Present
New York State Society of Anesthesiologists 1984 - Present
International Anesthesia Research Society 1984 - Present
American Academy of Pain Management 2003-present
American Society of Interventional Pain Physicians 2003-present
Fellow of Interventional Pain Practice 2006-present
World Institute of Pain 2006-present

New Mild Treatment

NEW TREATMENT FOR SPINAL STENOSIS

The Pain Management Center at ELIH offers the MILD procedure for treatment of Lumbar Spinal Stenosis (LSS). "I see many people with lumbar spinal stenosis (LSS) and now have a longer lasting treatment option for this disease. I am pleased to introduce this safe and effective outpatient treatment to the East End community," says Frank J. Adipietro Jr., Pain Specialist who has three Board Certifications in Anesthesia and Interventional Pain Management.

What is the MILD procedure?

It is performed under fluoroscopic imaging to remove portions of the bone adjacent to the narrowed area restoring space in the spinal canal.

MILD requires local anesthesia and light sedation with sterile technique in the operating room. The patient may return home the same day.

The bony channel that encloses the spinal cord is called the spinal canal. Usually, there is enough space between the spinal cord and the spinal canal to allow nerves that flow through and exit the spinal canal to be free of obstructions. As your body ages, the ligaments and bones outside the spinal canal may thicken and begin to press on the spinal canal, causing it to narrow. This narrowing of the canal can compress or pinch nerve tissues, resulting in pain, numbness and disability. This narrowing or stenosis in the lower back, called Lumbar Spinal Stenosis (LSS), is a common cause of low back or leg pain, and is diagnosed in 1.2 million patients annually in the USA.

Symptoms may include:

Dull, aching pain in your back that spreads to your legs once you are up and moving around.

Numbness in your legs or a “pins and needles” sensation when you’re active.

Grocery shopping or just getting the mail can become a painful chore that requires resting or sitting in order to relieve the leg pain.

Lumbar Spinal Stenosis (LSS) can be treated with pain medication, epidural steroid injections or physical therapy. When these conservative pain management therapies fail, the MILD procedure can provide an effective alternative to a major back, laser or endoscopic surgical procedures.

FAQ EPIDURAL SHOT

The following Frequently Asked Questions and answers are for epidural steroid injections. It is one of the most commonly performed procedures at ELIH.

The following material is given as general information only, and is not to be considered as medical advice or consultation.

CONTACT INFORMATION

You may always contact us at 631.477.5353. Please ask for Eileen Verity, Dr. Adipietro or any of our excellent staff will be happy to address additional questions or concerns you may have. Please feel free to call at any time.

WHAT IS AN EPIDURAL STEROID INJECTION?
An epidural steroid injection is the administration of long lasting steroid (Triamcinolone, Depo-Medrol or Celestone) into the epidural space, which is the area surrounding the spinal cord and nerve roots. All of the nerve roots in the spine are covered with a protective sheath called the dura. When a prescribed amount of saline or long-acting local anesthetic agent (Bupivacaine) combined with a steroid medication (Triamcinolone, Depo-Medrol or Celestone) is injected adjacent to the affected nerve root, significant pain relief is often obtained. This is performed by a Board Certified Anesthesiologist, with subspecialty training in Interventional Pain Management and Pain Medicine. Anesthesiologists are trained early in their careers in the use of epidural placement techniques, which they then use on a daily basis to administer regional anesthesia in the operating room, and in the obstetric units to provide analgesia for childbirth. Their extensive experience with this technique makes them specially suited for this procedure.

WHAT IS THE PURPOSE OF THE EPIDURAL STEROID INJECTION?
Asteroid injection reduces the inflammation and swelling of nerves in the epidural space. This will reduce pain, tingling, numbness and other symptoms caused by nerve inflammation or swelling. It also serves a diagnostic purpose in which the physician can obtain significantly useful information, depending on the patient’s response. Epidural injections are often recommended as an alternative, or at least an attempt to ward off the need for surgery. You may also have a condition in which surgery would never be of benefit, and the epidural injections may provide an alternative form of treatment.

HOW DOES AN EPIDURAL STEROID INJECTION WORK?
There are two ways that epidural steroid injections work. Pain involves the inflammation of one or more nerves in the spine. The injection of steroids directly into the part of the spinal column called the epidural space aids in reducing this inflammation. Secondly, steroids act like a local anesthetic decreasing the pain long enough to allow the body to begin the process of repairing itself. The primary goal of an epidural steroid injection is to reduce pain. Relief could last weeks, months, or even years. On the other hand, some patients experience little or no relief.

HOW LONG DOES THE INJECTION TAKE?
The actual injection takes a few minutes.

WHAT IS ACTUALLY INJECTED?
The injection consists of a mixture of saline or a long-acting local anesthetic (Bupivacaine) and a steroid medication (Triamcinolone, Depo-Medrol or Celestone).

WILL THE INJECTION HURT?
The procedure involves inserting a needle through the skin and deeper tissue (like getting blood drawn). There is minor discomfort involved. However, we numb the skin and deeper tissue with a local anesthetic (Lidocaine) using a very thin needle prior to inserting the epidural needle. In fact, the worse part is usually the injection of the numbing medicine, which will feel similar to a bee sting. Most of the time you will feel a strong pressure and not much pain.

WILL I BE “PUT OUT” FOR THIS PROCEDURE?
No. This procedure is done under local anesthesia. Doing this procedure with the patient under general anesthesia or heavy sedation is contraindicated since it can lead to serious complications.

HOW IS THE INJECTION PERFORMED?
It is done with the patient sitting up using fluoroscopic (x-ray) guidance. The area is cleaned with antiseptic solution, local anesthesic (numbing medication) is injected, then the epidural steroid injection is performed. In most cases, this process takes 3 to 5 minutes. After the procedure, you are placed on your back or side until ready to stand.

WHAT SHOULD I EXPECT AFTER THE INJECTION?
Immediately after the injection, you may notice that your pain may be decreased or completely resolved. This is due to the local anesthetic. This will last only for 4 to 6 hours. Your pain will return and you may actually have more pain than usual for a few days. This is from the mechanical process of the needle insertion as well as initial irritation of the steroid. You should start noticing pain relief several days after the injection. Although the steroid will begin to work immediately after the injection, it will take 5 to 6 days for the swelling to diminish. Please remember that this is what takes place for the average patient, meaning that there are some that get immediate relief, while others may require 1 to 2 weeks to experience the full benefits.

WHAT SHOULD I DO AFTER THE PROCEDURE?
We advise patients to take it easy for 24 hours, then you may resume regular activities and return to work. Please remember to remove the bandage one day after the procedure.

HOW LONG DOES THE EFFECT OF THE MEDICATION LAST?
The immediate effect is usually from the local anesthetic injected. This wears off in 4 to 6 hours. The steroid starts working immediately after being injected, but most patients will not feel a difference until 5 to 6 days after the injection. This effect can last for several days to months or significantly longer.

HOW MANY INJECTIONS DO I NEED TO HAVE?
After the first injection you will return in three weeks for a second epidural injection. Depending on your symptoms, additional injections may be indicated. It is recommended that no more than three injections be done in a six-month period, or six in a one-year period. It is also not recommended to continue with injections for more than a year, if no long-term relief is achieved.

CAN I HAVE MORE THAN THREE INJECTIONS?
In a six-month period, we generally do not perform more than three injections. This is because the medication injected may last up to six months. If three injections have not helped much, it is very unlikely that you will get any further benefit from additional epidural injections. Other techniques should be performed if the first series of injections afford little relief.

WHAT RESULTS CAN BE EXPECTED?
Generally most arthritic conditions of the neck or back with or without nerve-root symptoms (arm or leg pain), will obtain varying degrees of relief. Overall, approximately 50-75% of patients receive moderate to excellent pain relief. The relief is often permanent, especially in self-healing conditions such as mild “bulging” or "herniated" discs. For more severe conditions, relief depends on the amount of time that the patient has been in pain. In cases of severe nerve root compression syndromes (pressure on a nerve), the therapeutic pain relief will often be very brief. Significant pressure on a nerve may only improve by surgically removing part of the herniated disc. For other conditions, especially arthritic induced pain, 2 to 3 months of relief can be seen. A trial of two may be given, but usually no more than three are recommended over a six-month period.

WILL THE EPIDURAL STEROID INJECTION HELP ME?
It is very difficult to predict if the injection will indeed help you. Patients who have “radicular symptoms” (arm or leg pain) respond better to the injections than patients who have only neck or back pain. Though certain types of neck or back pain from a bony abnormality will derive considerable benefit from the injections. Similarly, patients with a recent onset of pain may respond much better than the ones with long-standing pain.

WHAT ARE THE RISKS, SIDE EFFECTS AND POSSIBLE COMPLICATIONS?
This procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The most common side effect is back or neck pain and spasms, which are temporary. Other risks include dural puncture with possible spinal headaches. Bleeding is more common in patients with genetic predispositions like Hemophilia, or patients taking blood thinners such as Coumadin, Warfarin, Plavix, NSAID's, anti-inflammatory medications, Lovenox or Aspirin. Bleeding into the spine may cause compression of the spinal cord with resultant paralysis. This would require emergency decompresive surgery and there would be no guarantee of recovery. Rarely, an infection may occur leading to meningitis.

Risks and side effects related to the medications include: weight gain, elevated blood sugar in diabetics, water retention, suppression of the body’s own natural production of cortisone as well as temporary suppression of the immune system. Minor temporary side effects are seen in 1-2% of patients: puffy red cheeks (facial flushing) or ankle swelling from fluid retention. Because the injection occurs next to an inflamed nerve root, sensations of increased pain, numbness in one or both legs, and difficulty voiding can occur temporarily. Rarely, side effects can occur including: steroid myopathy (weakness of the thigh muscles), temporary steroid psychosis, possible worsening of osteoporosis if present, and congestive heart failure.

Other side effects of the steroid medications include: low-grade fevers, hiccups, insomnia, headaches, increased heart rate and abdominal cramping or bloating. These side effects occur in only about 5% of patients and commonly disappear within 1-3 days after the injection.

WHO SHOULD NOT HAVE THIS INJECTION?
Patients allergic to any of the medications to be injected, on blood thinning medication (Coumadin, Warfarin, Plavix, NSAID's, anti-inflammatory medications, Lovenox or Aspirin), with bleeding disorders (Hemophilia, Thrombocytopenia or any other Coagulopathies), or have an active infection should not have the injection.

HOW SHOULD I PREPARE FOR THE PROCEDURE?
Stop any blood thinners (Coumadin or Warfarin) 4 days prior to your procedure. Always consult your primary care physician before stopping these medications. All antiplatelet medications (Plavix, NSAID's, anti-inflammatory medications, Lovenox or Aspirin) will need to be stopped 7 days prior to the procedure.

If you have a cold or an active infection, please call The Pain Center and reschedule the procedure for a later time. Remember that steroids may temporarily depress your immune system possibly worsening the infection.

PREDICTIVE FACTORS
Patients with classic disc related syndromes (arm or leg pain) with symptoms of less than 3 months duration have an excellent chance of symptomatic relief by epidural steroid injections. Epidurals have a lesser effect on patients with symptoms persisting for periods longer than 3 months or in patients treated previously by surgical methods.

CONCLUSION
Conclusions made after reviewing the studies are: two thirds of paients with acute disc related disease will benefit from epidural steroids. Only one third will benefit after 6 months. Three weeks after an epidural steroid injection the patient should be reevaluated. If there is significant improvement in function and subjective pain relief, a second epidural steroid injection is administered. If there is no change in the patient's condition after the first injection, an alternative intervention is sought. Because epidural steroid injections are often the last recourse before surgery, the benefit of up to three injections in a six month period should be considered for patients with pain related to neck or back problems.

FAQ ABOUT PAIN

Should I apply ice or heat to an injury?
Ice should be used in the acute stage of an injury (within the first 24-48 hours), or whenever there is swelling. Ice helps to reduce inflammation by decreasing blood flow to the area in which cold is applied. Heat increases blood flow and may promote pain relief after swelling subsides. Heat may also be used to warm up muscles prior to exercise or physical therapy.

What is physical therapy? Physical therapy is the treatment of musculoskeletal and neurological injuries to promote a return to function and independent living. Physical therapy incorporates both exercise and functional training. Exercise restores motion and strength while functional training facilitates a return to daily activities, work, or sport.

What is a cortisone/corticosteroid injection?
Cortisone is a steroid that is produced naturally in the body. Synthetically-produced cortisone can also be injected into soft tissues and joints to help decrease inflammation. While cortisone is not a pain reliever, pain may diminish as a result of reduced inflammation. In orthopedics, cortisone injections are commonly used as a treatment for chronic conditions such as bursitis, tendinitis, and arthritis.

What is an epidural? An epidural is a potent steroid injection that helps decrease the inflammation of compressed spinal nerves to relieve pain in the back, neck, arms or legs. Cortisone is injected directly into the spinal canal for pain relief from conditions such as herniated disks, spinal stenosis, or radiculopathy. Some patients may need only one injection, but it usually takes two or three injections, given two weeks apart, to provide significant pain relief.

What are NSAIDs and how do they work?
Non-steroidal anti-inflammatory drugs (NSAIDs) are non-prescription, over-the-counter pain relievers such as aspirin, ibuprofen, and naproxen sodium. They are popular treatments for muscular aches and pains, as well as arthritis.

NSAIDs not only relieve pain, but also help to decrease inflammation, prevent blood clots, and reduce fevers. They work by blocking the actions of the cyclooxygenase (COX) enzyme. There are two forms of the COX enzyme. COX-2 is produced when joints are injured or inflamed, which NSAIDS counteract. COX-1 protects the stomach lining from acids and digestive juices and helps the kidneys function properly. This is why side effects of NSAIDs may include nausea, upset stomach, ulcers, or improper kidney function.

What is the difference between x-rays, MRI, and CT scan? X-rays are a type of radiation, and when they pass through the body, dense objects such as bone block the radiation and appear white on the x-ray film, while less dense tissues appear gray and are difficult to see. X-rays are typically used to diagnose and assess bone degeneration or disease, fractures and dislocations, infections, or tumors.

Organs and tissues within the body contain magnetic properties. MRI, or magnetic resonance imaging, combines a powerful magnet with radio waves (instead of x-rays) and a computer to manipulate these magnetic elements and create highly detailed images of structures in the body. Images are viewed as cross sections or "slices" of the body part being scanned. There is no radiation involved as with x-rays. MRI scans are frequently used to diagnose bone and joint problems.

A computed tomography (CT) scan (also known as CAT scan) is similar to an MRI in the detail and quality of image it produces, yet the CT scan is actually a sophisticated, powerful x-ray that takes 360-degree pictures of internal organs, the spine, and vertebrae. By combining x-rays and a computer, a CT scan, like an MRI, produces cross-sectional views of the body part being scanned. In many cases, a contrast dye is injected into the blood to make the structures more visible. CT scans show the bones of the spine much better than MRI, so they are more useful in diagnosing conditions affecting the vertebrae and other bones of the spine.

PAIN RELIEF: A MULTIDISCIPLINARY APPROACH

By: Frank Adipietro, MD

What was the worst pain you can remember? Was it childbirth? Kidney stone years ago? Or the time you scratched the cornea of your eye?

Unfortunately, it is unusual not to have experienced some sort of pain at some point in your life. Mercifully though, the relief always came. The stone passed. The baby was born. Doctors call these types of pain, acute pain.

The body sustains an injury and will likely heal itself. However, if the healing process is protracted or incomplete, the pain becomes chronic. Chronic pain is different. Chronic pain lingers. Pain signals in the nervous system fire for weeks, months or even years.

As with all chronic illness, long lasting pain will lead to depression, insomnia, isolation and hopelessness. The treatment of chronic pain requires a multidisciplinary coordination, the specialists often involved in this type of care include: the family practitioner, orthopedist, neurologist, neurosurgeon, psychiatrist, physical therapist, or for cancer related pain, a hematologist oncologist, as well as a pain management specialist.

Often, the family practitioner performs the initial evaluation on patients who first seek medical treatment for back pain, neck pain or shingle pain, for example. Eventually, there may be referrals to other specialists. Physicians must educate the patient and their family members to understand the disease process, prognosis, causes of pain as well as the numerous and varied steps taken to undo what pain has done. This is why a good patient/doctor relationship is critical to the overall success in these cases.

When pain is constant and does not subside, a patient may be referred to a physician who specializes in the management of pain. Frequently, these are medical doctors who practice anesthesiology as a primary specialty and have extensive fellowship training in pain management.

Prior to 1993, fellowship training was not a requirement. Now, however, sub-specialty training is part of every residency program. A pain management specialist is integral to the treatment plan and ultimate disposition. The Pain Management Center at Eastern Long Island Hospital offers these sophisticated treatments for pain management services.

Low back pain is an extremely common problem seen in your local emergency room as well as a frequent cause for missed workdays, second only to the common cold. If you have ever experienced an acute episode of low back pain, you will appreciate how doing daily activities seems nearly impossible.

The good news is that most acute cases are not serious and respond to simple pain management treatments. Unfortunately, some pain can be severe and extremely debilitating. This pain can limit activity, reduce work capacity, and alter the quality of life.

What are the primary causes of back pain?
Muscle strain often occurs when the muscles of the lower back are poorly conditioned and subsequently overused. Herniated discs, sciatica (pinched nerve), spinal stenosis (arthritic back) and age related degeneration of the discs (degenerative disc disease) are other reasons for chronic back pain. Muscle strain is most amenable to physical therapy or rehabilitation. A short period of rest and medication to diminish inflammation is usually the first treatment option. As the initial pain eases, a rehabilitation program will strengthen back and abdominal muscles, increase flexibility through stretching, and, in some cases, include a weight loss program. I

f the initial pain persists, or physical therapy proves to be too uncomfortable, further testing with a MRI or CT scan may be necessary. A consultation with an orthopedist or referral to a pain management center may also be indicated. A pain specialist may suggest epidural steroid injection (ESI) as a treatment option after evaluation. Epidural steroid injection is a safe treatment modality, successfully used for over 40 years for back pain. The injection contains a powerful anti-inflammatory agent, cortisone, which is placed into the epidural space, located around the spine. ESI is a common procedure, and because of low risk and low incidence of problems is a reasonable alternative after other conservative therapies have failed to provide any measurable relief.

ESI is performed as an outpatient procedure without sedation in about 5 to 10 minutes. It is usually no more uncomfortable than having blood drawn. The main goal is to shrink the swelling in herniated discs, around a pinched nerve, or diminish the inflammation associated with some forms of spinal stenosis. Improvement after the first treatment may be immediate or may take up to two weeks. Patients are advised to rest on the same postoperative day.

Gradually, normal activity should resume when coordinated with physical therapy. Physical therapy should be better tolerated after the injection. Generally, an accepted practice is to repeat the injections two more times over the next two months for an additive effect. Initially, weekly postoperative follow up will gauge clinical response as well as side effects. Adverse reactions and side effects are rare. Some include fluid retention, acne, headache, infection, and bleeding. Clinical response varies from partial to complete relief in a large number of patients to a small percentage with no real improvement. If the injections provide little or no relief, surgical evaluation may be the next option. If a surgeon has seen the patient prior to the pain specialist, frequently a trial of epidural injections will be prescribed as an alternative before surgery is seriously considered.

Similar pain management procedures are prescribed for head and neck pain, shingles, trigger point pain, and sacroiliac arthritis. These and other treatment modalities are available at the Pain Management Center at Eastern Long Island Hospital.

Pain Case Studies

MINIMALLY INVASIVE RELIEF OF LOW BACK PAIN
By: Frank Adipietro, MD

Agonizing and sometimes debilitating, back pain can be experienced by people with contained herniated discs, an injury that strikes nearly one and a half-million Americans each year. Commonly referred to as a "thrown-out back" or "pinched nerve," this injury can be accompanied by intense pain in and around the affected disc as well as in surrounding areas of the lower back and legs.

A disc, sandwiched between the spinal vertebrae (back bones), is composed of two parts: a hard protective outer shell called the annulus, and soft, spongy tissue at the center called the nucleus. A healthy disc acts like the shock absorber of an automobile, providing a cushion against jolts caused by simple movements like running or jumping. If the annular ring, or the protective shell of the disc, is damaged by injury or weakened by normal aging processes, a portion of the shell can give way to pressure from the central spongy nucleus, causing an outward bulge. It is this unnatural bulge, or "herniation," that is often responsible for the patient's back or leg pain. Typically a bulge will put pressure on either an adjacent nerve root or on the spinal cord. It is this compression of the nerve pathway that causes the patient to feel pain in the parts of the body served by the nerves.

For example, when the spinal cord is compressed, pain is felt in the back, whereas nerve root compression is accompanied by pain in both the back and legs. A technique called percutaneous disc decompression works like letting air out of a bicycle tire. By removing tissue from the center of a disc there is a reduction of pressure within the disc. This then leads to a reduction in the pressure that the disc applies to nerve roots or the spinal cord. The disc decompression is performed through a minimally invasive catheter or thin needle. This type of procedure, performed through the skin, or 'percutaneously', minimizes trauma to the patient leading to shorter hospital stays and faster recovery compared to traditional open surgical techniques. Usually the patient is home 2 hours after the procedure. Percutaneous disc decompression has been used in the treatment of herniated discs for over 30 years and in over 500,000 patients.

A variety of techniques have been used to decompress discs, including chemical, mechanical, and thermal/heat (radio frequency and laser) methods. While the basic mechanism of percutaneous disc decompression has been well understood, each of the previous methods has had limitations.

No method has adequately addressed all of the issues inherent in disc decompression - until now. The Disc Nucleoplasty procedure is a recent and significant leap forward in minimally invasive disc decompression therapy. Disc Nucleoplasty is performed percutaneously through a small needle, resulting in minimal trauma and fast recovery times. Because of this, Disc Nucleoplasty disc decompression is performed while the patient is awake, requiring only local anesthesia and light sedation. The difference between Disc Nucleoplasty and other methods of percutaneous disc decompression is Coblation® technology. This enables the Interventional Pain Management Specialist to combine tissue removal with thermal treatment to achieve disc decompression quickly, efficiently and safely because the needle tip is kept at a lower temperature than other techniques.

Coblation technology has been used successfully in over 2 million other procedures since its introduction in 1995. Since it's first application in July 2000, the Disc Nucleoplasty procedure has been used to treat over 20,000 patients. During this time a variety of peer reviewed and published studies have demonstrated both the safety and effectiveness of the procedure. It has quickly become a leading treatment for symptomatic patients with contained herniated discs. Accordingly, it has become a leading method for performing minimally invasive disc decompression, the choice of Interventional Pain Management Physicians across the USA and around the world.

The ideal patient for percutaneous disc decompression suffers from back and/or leg pain caused by a contained disc herniation. The procedure is much like having an epidural steroid injection. First you will be given a local anesthetic and light sedation. Then your Pain Management Physician will insert a needle into the center of the herniated disc. The needle emits radio waves that dissolve excess tissue, reducing the size of the bulge. This relieves the pressure inside the disc and also on the nerves. When the pressure is relieved, the symptoms are relieved. Recovery is rapid and usually occurs within 8-10 days. 80% of properly selected patients will have significant long-term relief of their symptoms.